The Shift
Page 1
THE SHIFT
One Nurse, Twelve Hours, Four Patients’ Lives
THERESA BROWN
ALGONQUIN BOOKS OF CHAPEL HILL 2015
To Sophia, Miranda, and Conrad—
the beginning of this journey
If all is supposition, if ending is air, then
why not happiness? Are we so cynical,
so sophisticated as to write off even the
chance of happy endings?
—TIM O’BRIEN
In the Lake of the Woods
So we come down from stony haunts—
the hypothetical eternal—to find another
way into the garden . . .
this time we’ll pick the other Tree
and eat the fruit of life.
— ELEANOR WILNER
“Sarah’s Choice”
Disclaimer: This book is a work of nonfiction and the stories told here are true, drawn from my time spent working as a bedside nurse on a bone-marrow transplant/medical oncology floor in a teaching hospital in Pennsylvania. Specific details have been changed to conceal the identities of patients and coworkers, and in the interest of protecting patient and staff confidentiality some characters are composites. Conversations and events in The Shift are reproduced to the best of my memory, though I have altered some short exchanges for clarity. The real patient behind the character of Ray Mason in The Shift gave me permission to tell his story here. HIPAA requirements make it potentially illegal for hospital nurses to track patients down after they’ve been discharged from the hospital and I did not attempt that for the other patients in this book. To avoid casting aspersions on a particular practice group I made up the incident where a procedure is done only because a patient requests it. Similar events have happened in the hospital, though. Finally, this book is not a medical textbook and should not be used as such: highly individual cases are discussed and are not necessarily suggestive of disease or treatment effects in the aggregate. All errors are my own.
CONTENTS
Prologue: A Clean, Well-Lighted Place
Chapter 1: 7:03 a.m.
Chapter 2: Report
Chapter 3: Hitting the Floor
Chapter 4: Worries
Chapter 5: Surgical Team C
Chapter 6: Paperwork
Chapter 7: No Time for Lunch
Chapter 8: Duo Damsel
Chapter 9: Judgment Calls
Chapter 10: Faith
Chapter 11: Revolving Door
Chapter 12: End of Shift
Afterword: Knowing the Future
Acknowledgments
About the Author
About Algonquin
PROLOGUE
A Clean, Well-Lighted Place
The buzz of the alarm surprises me, as it always does. Six a.m. comes too soon. I’ve been off for a few days and never go to bed early enough before a first shift back. That’s the problem with being a night owl at heart.
I lie in bed and think, What if I just don’t go in today at all? I consider it, then realize how much the nurses I work with would hate me if I didn’t show up.
I close my eyes one last time, though. It feels good to float in the warm darkness, Arthur, my husband, asleep next to me. There won’t be any floating once I hit the hospital floor. I’ll have drugs to deliver, intravenous lines to tend, symptoms to assess, patients in need of comfort, doctors who will be interested in what I have to say and others who won’t, and my fellow RNs, who with a combination of snark, humor, technical skill, and clinical smarts, work, like me, to put our shoulders to the rock that is modern health care and every day push it up the hill.
The memory of that effort comes back to me, keeping me in bed, but there’s something else, too, some feeling I don’t want to own up to. It’s why I’m hiding under the covers: I’m afraid. Afraid of that moment when the rock slips and all hell breaks loose.
For me it was the patient who started coughing up blood and within five minutes was dead, just like that. I’ve told the story many times, written about it, thought about it. Seven years later it has gotten easier. But remembering it I feel a flutter in my stomach, a tightening of my jaw.
That day the rock wrenched itself free, and until then I hadn’t fully understood that we could completely lose control of a body in our care. It wasn’t for lack of exertion; it was destiny, or fate if you prefer, that tore the rock away from me. I had run after it hard and fast, doing CPR in scrubs splattered with blood and calling in the code team—those professionals, usually from the ICU, trained for “rapid responses,” who try to rescue patients when they crash. The nurses and doctors did their best for this patient, but they couldn’t save her, and in the end a person who’d been alive and talking and laughing was living no more.
I put that memory away, get out of bed. It’s early November and dark out and I prepare for Pittsburgh’s late-autumn weather by pulling on riding tights and my wool sweater that proclaims “Ride Like a Girl.” The sweater makes me feel young.
Brushing my hair, I almost forget to put on my necklace—a small silver heart charm surrounded by the words “I” and “Y-O-U.” The heart has the tiniest of rubies stuck in the center, so that when it catches the light it seems to glow with life, like a human heart. Arthur gave me the necklace for our anniversary a few years back. I reach behind my neck with both hands and secure the clasp, comforted by having a reminder of love in the hospital.
As I move down the stairs, the house is hushed. Arthur remains asleep, as do our three children. I think about the sleeping kids, and a smile crosses my face: our son is fourteen, our twin daughters, eleven, all with variations on their dad’s curly hair, the girls blond, as I used to be, too. None of them will get up for school until long after I’m gone. The dog doesn’t even wake up with me in the morning, but the truth is, I like it quiet like this. The warm blue of our cabinets and our pot rack in front of the kitchen window make me happy. In the silence of the morning I take a mental snapshot of the kitchen as a dose of home. Home is a vaccine against the stresses of nursing.
Oh, food! I pick up a banana from our fruit bowl, peel it fast, and then eat it while drinking a glass of water. I should scramble eggs, toast bread, or even pour a bowl of cereal, but I don’t get up early enough to do any of that, and anyway I’m not hungry first thing in the morning. My mother tells me my eating habits around work are unhealthy. Uh-huh. She’s right, and the irony is not lost on me, but the shift starts at 7:00 a.m. and I’m never hungry until 9:00. I can’t change that.
Lunch? I grab a yogurt, an apple, slap together a turkey sandwich, light on the mayo, and stow it all in my bike bag. The cafeteria food all tastes the same to me so I try not to buy my lunch. I see my reflection in the glass sliding door. Don’t have my game face on yet: my blue eyes look wary, waiting. The house remains silent as I sit on the stairs and tie my biking shoes. Then I put my bright yellow Gore-Tex jacket on, wrap my neck for warmth, and slide my bag over my shoulder.
I head down into what a friend calls our Norman Bates basement. It’s where I keep my bike. There’s no dead mother down here preserved with taxidermy, although you could find more than a few cobwebs and the sparse lighting makes the corners impenetrable. As a child I was terrified of the basement in our house and my best friend loved to tell stories about horrors befalling innocent young girls in creepy basements. I wonder why I listened to her. I must have enjoyed the thrill, that frisson of fear that came from transforming our very ordinary cellar into a place of the macabre.
My bike is stacked up against our family’s four other bikes. The basement is limbo, a portal between the ordinary joys and struggles of home and the high-stakes world of the hospital. I put on my helmet and lock the basement door behind me as I leave, awkwardly carrying my bike out the low door and
up the few steps. As usual, I’m running late. I turn on my bike lights, saddle up, and push off.
It’s two miles to the hospital and the ride starts with a downhill. I enjoy the feeling of moving without work, having the world shoot past as I pick up speed, my front light illuminating a slim strip of road. I barely brake at the first stop sign, making a quick left down an even steeper hill that makes me go even faster. The rush is fun.
The next bit, mostly flat, gives me time to think. Like many nurses, the thing I’m always worried about is doing either too much or too little. If I sound an alarm and the patient is OK, then I over-reacted and have untrustworthy clinical judgment. If I don’t call in the cavalry when it’s needed, then I’m negligent and unsafe for patients. You don’t always know because what goes on inside human bodies can be hidden and subtle. This job would be easier if there weren’t such a narrow divide between being the canary in the coal mine and Chicken Little.
I push hard during the one small uphill on my way to the hospital, neck scarf up and over my mouth. The cold makes the passageways in my lungs constrict when they shouldn’t, giving me that scary feeling of not being able to fully draw in a deep breath: bronchospasm. Covering my mouth and nose with a fleece wrap warms the air enough that I breathe just fine. I could carry an asthma inhaler, too, the medication that reopens those passageways, but that feels like overkill. At work I’ll pump medicine costing $10,000 a bag into patients’ veins, but use an inhaler? Me? That’s for people who are sick.
There’s not a hint of sunrise at the hospital parking lot, but cars scoot in and out of the gated entrance: the start of change of shift even though the day hasn’t yet officially broken. I glide in around the barricade to the metal bike rack just inside the parking garage on my right.
In the parking lot nurses, doctors, patients, family, friends drive in expectant, worried, excited, hurting. They grip glowing cell phones, hard-to-read pagers, pieces of paper, extra clothing, all while waiting impatiently, anxiously, expectantly for the elevator.
The hospital itself is a paradox. Despite its occasional terrors, it is undeniably an oasis for the ill and infirm, a clean, well-lighted place. Sick people come, bringing their hopes and fears and we minister to them with our, mostly, good intentions.
That phrase “a clean, well-lighted place” comes from a Hemingway story. It’s a short short story, about five pages long, in which, really, not much happens. The main character is a middle-aged waiter who works in a late-night café. He says some people require “a clean, well-lighted café” and late at night especially. Because of his own insomnia he understands why in the wee hours someone might need somewhere to go that’s not home and not a bar.
But the young waiter he works with doesn’t agree that the café needs to stay open so late. “Hombre, there are bodegas open all night long,” he complains, eager to close up, go home, be with his wife.
“You do not understand,” the older waiter says, “This is a clean and pleasant café. It is well lighted. The light is very good.” It’s two thirty in the morning and their one customer is an elderly man, a drunk who, the week before, tried to kill himself. If necessary, the older waiter will keep the café open all night to give sanctuary to this one forlorn soul.
However, his generosity to the patrons of the café stems not from compassion only, but his own hopelessness as well: “It was not fear or dread. It was a nothing that he knew too well. It was only that and light was all it needed and a certain cleanness and order.” A feeling of dark disorder has overtaken him and he keeps the café open in part to keep his own nihilism at bay. But he also knows something the eager young waiter does not. There will come a time when each of us will need a clean, well-lighted place that stays open all day and night, offering shelter from life’s storms.
This is a hospital.
I work on a cancer ward, and while “cancer” used to always imply “death,” more often than not that’s not true anymore. Now, cancer involves treatment and its accompaniments: chemotherapy, radiation, surgery, scans, clinic visits, and hospital stays. People survive, often. We cure them—put their cancer into remission, forever one hopes—and they go home. Indeed, an oncology nurse’s favorite words to a patient are, “I hope I never see you here again,” and we’re telling the truth.
The older waiter and I both come to work with the hope of doing good, and we share the same wish: for our customers, or patients, not to need us. But until that moment comes we will remain at our posts, ready.
AS I TAKE OFF MY GLOVES to lock up my bike, I shake my head. My friend Beth, another nurse at work, told me when she started this job she used to stop her car and vomit on the way to the hospital. I arrive with my heart racing from the bike ride, but the exercise also mellows my pre-work unease. Here I am, a forty-five-year-old mother of three with a PhD in English working as a nurse. People in health care—other nurses, doctors—weren’t sure about me at first, thought I’d made a strange choice in choosing nursing over teaching. Now they’re used to me. I show up and try hard; for everyone who counts, that seems to be enough.
The November cold nips at my bare hands as I walk toward the hospital, but as soon as I step inside the sliding glass entry doors blasts of warm air hit me. Sweat pricks on my back and I shimmy out of my bright yellow jacket, unzip my wool sweater, unwrap my neck, all while walking. I’m propelled by forward momentum and will stay that way for the entire twelve hours of my shift. It’s good I work only three days a week. I live the other four days at a more normal pace.
A few nurses in white scrubs pass me on their way out and a few younger docs in white coats sleepily make their way down the hall ahead of me, their pockets bulging with folded papers. A surgeon I recognize steps out of the cafeteria gripping a paper cup of coffee from which he aggressively sips, though it’s clearly steaming hot.
Two fresh-faced residents—new MDs in the middle of their on-the-job training—get on the same elevator I do, heads buried in their notes, talking excitedly in our shared language of medical acronyms, polysyllabic procedures, and body parts. An ICU nurse I’m friendly with steps on next, wearing the characteristic blue scrubs. A housekeeper carrying extra trash bags and a dry mop slides in just before the door closes.
“Hey,” says Karla, the ICU nurse, as she looks me up and down, takes in my tights, the waterproof jacket hung over my arm. “You rode your bike today?”
“Uh-huh.”
“Isn’t it cold?” she grimaces.
“Not once I get moving.”
“You’re nuts,” she says, waving as she steps off the elevator.
I laugh my loud laugh and wave back. Then she’s gone.
Biking to the hospital gives me an unexpected patina of toughness, which matters in health care. Hospitals are filled with caring staff, but resilience and determination are prized as highly as empathy. In the vernacular, it comes down to whether someone’s “got the balls” to make x, y, or z happen. The contrast between the empathy we’re supposed to have and constant talk of “growing a set” or “who’s got the cojones to . . .” can be jarring, but a big rock, no kidding, needs a nurse with the stones to move it.
I yawn, then chuckle to myself that a two-mile bike ride in the early winter cold hasn’t woken me up. The housekeeper catches my eye as I yawn again. “I hear that,” she says.
On my floor I change clothes in the general employee bathroom. We used to have a locker room with its own bathroom, but then they moved the locker room farther away, dolled it up, but forgot about a bathroom. I don’t really care, except I get dressed for work in here and God only knows what killer microbes live on the floor, no matter how often they clean it.
My bike clothes come off and I pull on white scrubs, chilled and stiff from the ride. Done. I give my face a glance, just long enough to make sure I’m not sweaty. No makeup because, as a nurse I know says, “This is a dirty job.” My necklace’s reflection catches my eye in the mirror: O-U-Y I. I reach up and wrap my fingers around it. Always, I think.
Grabbing my bike clothes and bag, I pad in my sock feet into our redecorated (but less hospitable) staff locker room. I give my combination lock a few fast, practiced spins and pop open the door. Here I have everything I need to get through the next twelve hours: ink pen, flashlight, scissors, tape, blue IV caps, alcohol wipes, saline flushes, and a Sharpie. I stuff all that stuff into the different pockets of my scrubs and hang up my biking gear.
My bike shoes go onto a communal rack in a corner of the room and I slide into my nurse shoes with their thick soles. Leaving my work shoes at the hospital insures that hospital germs stay at work, too. I clip my ID badge onto my scrub top, completing the transformation from regular person to nurse. My lunch, such as it is, goes into our staff refrigerator and as I swipe my ID down our time clock’s side channel I put on that game face while deliberately moving the pleasures and pulls of home to the back of my mind.
A shift lasts twelve hours. Twelve hours of holding a few lives in my hands, trying to make order out of the chaos of bodies and disease, working within a health care system that sometimes forgets it exists to serve human beings rather than bureaucrats or businessmen.
Amid the many uncertainties of the shift there is one thing I know for sure. Am I ready and up to the job? Yes. Today, and every day, for the sake of my patients I have no other option; the answer has to be, and always is, Yes.
CHAPTER 1
7:03am
I hit the floor at 7:03. It should be 7:00, but getting here almost late is my small, immature act of rebellion.
My very first clinical instructor told us, “If you’re early, you’re on time, and if you’re on time, you’re late.” There was no “And if you’re late . . .” Late being so catastrophic that its consequence couldn’t even be spoken of. But here I am at the hospital, three minutes late, and nothing at all happens.
My eyes are wide, my muscles tense, but there’s rarely any drama at the start of a morning shift. The floor is silent enough that my shoes make just the slightest squeak as I walk. In the hospital, if it’s a good day, nothing much real happens before eight or nine a.m.